Transcript
AFFIDAVIT CONCERNING CHILDREN JD-FM-164 Rev. 6-09 C.G.S. § 46b-115s P.B. § 25-57
STATE OF CONNECTICUT SUPERIOR COURT COURT OF PROBATE www.jud.ct.gov
INSTRUCTIONS Complete form. You must swear that your statement is true and sign it in front of a court clerk, a notary public, or an attorney who will also sign and date the affidavit.
Judicial District of
At (Town)
Probate District name and number
Plaintiff/Applicant (Last, first, middle initial)
Court Use Only
AFFACUS Docket number
Defendant/Respondent (Last, first, middle initial)
Information about the past five years for each child affected by this case is required. Provide information below. If more space is needed, use form JD-FM-164A. Child's name (First, middle, last)
Date(s) of residence
TO
Date of birth (Month, day, year)
Location (Town or city, and state, unless confidential by court order)
Name(s) and present address(es) of person(s) child lived with (unless confidential)
Relationship to child
THE PRESENT
TO
TO
TO
TO
Child's name (First, middle, last)
Date(s) of residence
TO
Date of birth (Month, day, year)
Location (Town or city, and state, unless confidential by court order)
Residence information is same as for child above. (If not same, provide information)
Name(s) and present address(es) of person(s) child lived with (unless confidential)
Relationship to child
THE PRESENT
TO
TO
TO
TO
(Continued...)
Check here if additional children are listed on JD-FM-164A.
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1. (Check one) I have I have not been a party or a witness or participated in any other capacity in cases in Connecticut or any other state concerning custody of or visitation with any child listed in this affidavit. If yes, identify the name of the court, the court case number and date of determination:
(Check item 2 or 3 below) 2.
I do not know of other civil or criminal proceedings in Connecticut or any other state, now or in the past, that could affect the current proceeding, including enforcement proceedings and proceedings relating to family violence, protective orders, termination of parental rights and adoption.
3.
I know of the following civil or criminal proceedings, in Connecticut or any other state, now or in the past, that could affect the current proceeding, including enforcement proceedings and proceedings relating to family violence, protective orders, termination of parental rights and adoption.
Case name
Docket number
Court location (Including state)
Docket number
Court location (Including state)
Nature of proceeding Case name Nature of proceeding
4. (Check one)
No one except the plaintiff/applicant and defendant/respondent has physical custody or claims to have custody or visitation rights regarding any child listed here. The following person(s) has physical custody or claims to have custody or visitation rights regarding any child listed here: Name: Address: (unless confidential)
5. The mother of the child(ren) named in the Complaint or Application is pregnant. Yes
No
Do not know
6. A child has been born to the mother named in the Complaint or Application after the filing of the Complaint or Application. Yes
No
Do not know
If yes, complete the following:
Child's name
Date of birth (Month, day, year)
Signature
Print name of person signing
Sworn to before me (Assistant Clerk/Comm. of Superior Court/Notary Public)
Date signed
JD-FM-164 (Back) Rev. 6-09
You have an ongoing duty to tell the court about any case that could affect the current proceeding, in Connecticut or any other state, if you learn about it during this case.
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